Background Investigations Process Service Claims Investigations

Preliminary Case Assessment and Investigative Plan Creation

 In News and Updates

All too often Insurance Adjusters and Claim Handlers delegate investigative assignments to professional investigative companies and provide the bare minimum intelligence to the investigative service provider. The provider may fail to request additional information for a variety of reasons.
A. They may be overworked and understaffed
B. Their Case Management personnel may not be properly trained or experienced in workers’ compensation claims management
C. Lack of attention to detail and lack of desire to always go above and beyond
When an Adjuster or Claim Handler provides detailed comprehensive background information, the investigative service provider has the ability to review the information presented, reach out for follow-up or clarification and then prepare a detailed investigative plan, consisting of a multiple pronged approach. That approach should consist, minimally, of the following:
A. A thorough and comprehensive preliminary internet and social media search
B. A comprehensive person search via a reputable information and intelligence provider
C. Motor Vehicle Drivers License and Vehicle Registration Searches, where permissible by state law
D. A review of previous investigative reports and all claim related documents, including forms submitted in support of the claim, witness statements, employer documents, medical documentation, IME reports, detailed physical restrictions, etc.
E. A thoughtful conversation with the Adjuster or Claim Handler concerning the present case status and direction in which the case is proceeding, any special considerations, and an understanding of expectations and limitations based upon the information provided, as well as a reasonable timeline and deadline for the requested investigative work
By utilizing a comprehensive, multiple pronged approach, the investigative service provider can fully understand the individual concerns pertaining to the file, as well as being able to properly assign personnel based upon strengths and capabilities in an effort to achieve the most beneficial results in a timely fashion, achieving the goals and deliverables requested by the Adjuster or Case Handler.
In doing so, the investigative service provider can best reduce the potential for damages by working proactively with the Adjuster as a team, with everyone focusing on the same goal, the development of actionable intelligence and documentary evidence for use and submission in workers’ compensation proceedings.
TOP Ten Steps that an Adjuster/Claims Handler Should Consider When Assigning an Investigation
1. Put procedures and training in place for all involved parties to learn proper injury management and correct post-injury response following a work-related incident.
2. Suspicious claims should be assigned to experienced adjusters.
3. Consider the use of predictive, analytic software which can review data and flag suspicious claims.
4. Once the initial injury is reported, the adjuster should thoroughly investigate precisely how the injury occurred and gather as much information from the claimant as possible.
5. Immediately contact the employer, the injured claimant, witnesses and medical providers to ask pertinent questions.
6. Record data in such a way that vital contact information that would be given to an outside investigator is readily available.
7. Avoid data entry errors especially with addresses and contact information which can lead to wasted time and money with regard to surveillance investigations.
8. One adjuster contact should be established as a foundation for the management of the claim and that adjuster should initiate claim communication with all concerned parties.
9. The main adjuster contact provides direction for further investigation and case management.
10. Hire an experienced investigation firm for compensation claims that have recovery potential. They can cost-effectively take over the role of thorough fact gathering and obtain evidence to refute fraudulent compensation claims.

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